What a good health care system is

There is a ritual in American politics every time a president  of the Democrat party comes into office. He will try to reform health care. He will be sandbagged by the right wing media attack machine and the medical  industry. The Canadian health care system will be held up as an ideal and  something for  middle class Liberal Canadians to feel smug about.
If the best that can be said about the Canadian health care system is that it is better than the American, then  Canada does not have much of a health care system at all. The World Health Organization (WHO’s) rating of countries according to their health care systems  does not speak well of our health care system either. Out of almost 200 countries, we are  thirtieth, and the United States is thirty seventh. 
We are behind countries like Columbia and Morocco. Yet  there is something  shaky about the WHO’s rankings. France is number one, yet  life expectancy there is two years  shorter  than in the United States. 
However, many Americans are turning from Canada as a model for a new  health care  system and looking at France.  Canada is alleged to be the realm of  ‘death panels’;  bureaucratic committees who decide who will get  life saving procedures and who will be left to die. Americans are said to want their ‘choice of physicians’ and do not want any bureaucracy standing in the way. 
This is to say that Americans  cannot think at all. They already have a horrible bureaucracy  interfering with their  health care; the medical  industry. Canadians are as free as people anywhere to “choose their personal physicians” but most of us know that this is a hollow freedom, especially when the number of physicians in practice is restricted; doctors are free to choose us, too. 
The French  people like their health care system.  They can ‘choose their physicians’, there are plenty of them to choose from, and everyone is covered.  They can buy ‘extra coverage’ if they want to; this  always  seems to make some people ‘feel better’. 
However,  most of the cost is still borne by the state and the French system is very expensive to operate. Any system whereby government buys services from private businesses, including privately practicing physicians, will be very expensive. World wide, most systems still operate that way.
Bismark and Beveridge
Since industrial nations began  setting up  health care systems  a century ago,  two  basic models have developed. In the Kaiser’s Germany old Bismark  created the first health insurance system. He required all employers to  provide health insurance for their employees.  
He and his successors  developed supplemental systems for   the unemployable and  such groups as farm workers. A network of ‘sick funds’ developed  in which  employers, employees, and the state all chipped in. Employers,  the state, and  labor unions all had a voice in operating these sick funds. 
After the second world war,  Great Britain’s first labor majority  government decided that it was time for a national  health service. This was designed by Lord Beveridge and is sometimes called the ‘single payer’ system. People go to their doctors for services, and then the doctor bills the National Health Service for it. 
In Britain, costs have been kept under control by negotiations between the medical association and  the governments bureaucrats about what gets done and how. The problem with this is that here is no real voice for the patient’s interest in this. 
Canada started out copying the Beveridge system but was chickened by intense opposition from the medical industry. A large private health insurance system  has been allowed to operate alongside the public one, reducing the overall quality of health care. The private system  increases its profits by  exerting a nefarious influence to insure that the public system is run badly. 
The systems of France and  the United States are essentially Bismark systems. But in the American system there are no controls at all, no regulating bodies. Private health insurance companies can charge whatever they  can get for health services. There is a single payer ‘medicare’ system but only for  those over  sixty five. 
The American system is famous  for leaving  a large portion of the population  with no health care whatsoever. Many more have very poor health coverage.  Health Insurance  corporations  can cherry pick their clients; it is said that the only way to get health insurance  in America is if you do not need it. 
Which of the two  models a country adopts seems to have less to do with the quality of health care than does the political culture of the country. The same is true for the wealth of a country. Individualism generally means bad health care for most people, a more communitarian attitude means better health care for most. 
A third way.
The is another model for organizing health care, but  organized medicine does not want  you to know about it. The exemplar in the world today is Cuba. It rates number thirty nine  on WHO’s scale.  Without  the American embargo on it, it would be in the top ten. 
What the Cubans  do is  simply to keep anything private out of health care and to have systems in place to protect the individual patient’s interests. Doctors are on salaries. They are poorly paid but have free housing; over their clinics. These buildings, called ‘consultarias’, are in every neighborhood in Cuba. There is also a system of ‘polyclinicas’ for dealing with more complex problems. Relatively little care is delivered in hospitals.
No one in Cuba pays anything for any medical service. Someone who does not like the  local  doctor can  go to the next nearest consultaria.  There are boards in  every neighborhood, connected with the network of community councils in Cuba, who oversee local medical care and mediate when necessary between the  patient and the system. 
It is pointless to ask  where the Cubans  got this system from, or who invented it, where it was first used. The same kind of arrangements seem to organically develop  whenever profit taking is excluded from  health care. 
Canada has a good contemporary example of  community based medical care;  Quebec’s Local Community Health Centers. These  were developed during the 1970’s and  have grown, despite  attempts at various times in various ways to  shut them down or limit them. They have  gradually taken on many functions   otherwise handled by hospitals. 
In pre medicare times in Canada, many communities organized their own health care clinics; the ‘cottage hospitals’ of Newfoundland, and the many locally run  hospitals on the prairies. Attempts to establish local health centers in many  communities in English Canada, to get more of  health care away from hospitals,  is  stymied by physician shortages, lack of funding,  and the  hostility of hospital unions, among other things.  
The United States had an impressive system of  community clinics for  poor neighborhoods until  the Reagan administration   cut funding for them. If they really want to make a start at reform their health care system they could reestablish this system. They need to start training many more doctors. They need to extend their present medicare system to the entire population. 
Canada, rather than  feeling smug,  could also follow  most of this advice. A truly good health care system is one that is community based, patient centered and free of profit motive.